Tennessee



Online Credentialing Application Now Available


You now have the option of submitting your credentialing application online or using the paper documents below. To complete the online application, click here


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Adobe Acrobat or Adobe Acrobat Reader is required to open the .PDF files listed below.

Re-Credentialing Application
Re-Credentialing Checklist
A provider checklist to ensure everything is included when the application is returned.
Tennessee Credentialing Application for Healthcare Practitioners
Provider Information Form
Location Information Update Form
Patient Feedback Survey
Provider Satisfaction Survey
Release Authorization
Signature and date verifying that all information is true and complete.
Business Associate Agreement
Terms of business relationship with ActivHealthCare. Must agree, sign and date.
Provider Agreement
Terms of provider membership with ActivHealthCare. Must agree, sign and date.
Certificate Holder Request Form
Request from your insurance company to list Integrated-ActivHealthCare as a certificate holder and verification of your professional liability insurance coverage as well as your medical malpractice claims history.
W-9 Tax Form